Monitoring Rates of Retention in HIV Care Across the State

Avnish Tripathi, MD, PhD, MPH


November 01, 2012

In This Article

Approximately 50% of HIV-infected individuals in the United States who are aware of their status fail to remain engaged in regular medical care. These data are concerning and warrant continuing efforts to monitor rates of retention, identify regionally relevant barriers that may impede retention, and develop integrated approaches to re-establish ongoing engagement in care.[1,2]

HIV/AIDS Surveillance Database as a Tool to Monitor Statewide Retention in Care

The majority of published data on retention in HIV care comes from large urban centers.[3,4,5] However, monitoring retention at a statewide level may have added advantages. First, it allows for inclusion of persons who may simultaneously and/or continually access different healthcare settings within the state. For example, a person with HIV infection receiving care at a private clinic may transfer care to a publicly funded clinic due to changes in insurance status or may be incarcerated or hospitalized but still receive HIV care. Second, compared with clinic-based data, statewide data may be better positioned to identify the most important sociodemographic and regional factors leading to disparities in retention across a wider population. Finally, statewide data could potentially provide objective feedback on the effectiveness of state policies and interventions for improving the rates of retention.

Collection of individual patient data such as missed appointments from all providers in a state would be a colossal endeavor, both financially and logistically. Alternatively, statewide HIV/AIDS surveillance data could be used to monitor various parameters of HIV care, including rates of retention after initial linkage in care, irrespective of the individual healthcare setting.

In recent years, many states have mandated reporting of all laboratory test results for viral load and CD4 count to the Centers for Disease Control and Prevention (CDC)-funded enhanced HIV/AIDS reporting system (eHARS) surveillance database.[7] Because these lab tests are only ordered by a licensed practitioner, the date of these tests could be used as a surrogate for an HIV care encounter.[8] In addition, eHARS contains information on basic sociodemographic characteristics, mode of transmission, and the initial viroimmunologic status at the time of diagnosis.

Linkage of eHARS with other surveillance databases such as that for sexually transmitted diseases and substance abuse as well as mortality registries offers an important opportunity to obtain empirical data on engagement patterns in HIV care.[9] Furthermore, geographic information system analysis on statewide surveillance data could allow for exploring the relationship of retention in HIV care with various important parameters, such as community viral load, accessibility to the nearest HIV healthcare setting, public transportation, regional poverty index, etc.[10] This approach is illustrated in the Figure.

Figure. An approach to the use of the eHARS database. *Agreements between the state health departments may facilitate exchange of information about residents receiving HIV care across the border in neighboring states. For example, the North Carolina Department of Health and Human Services shares information with the South Carolina Department of Health & Environmental Control about HIV/AIDS testing and CD4/viral load tests for South Carolina residents, and vice-versa.